NoteSwift for Amazing Charts Manual

Transcription

1 NoteSwift for Amazing Charts Manual Tips and Tricks to get the Most out of Your EHR NoteSwift 4989 Peachtree Parkway Peachtree Corners, GA /15/2013

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3 NoteSwift for Amazing Charts 2 Contents First Things First... 4 Assumptions:... 4 About This Document: Typographic Weirdness and Helpful Icons... 5 NoteSwift Forms... 6 Chief Complaint Form... 7 History of Present Illness Form... 8 Other Commands Available in the HPI Form:... 9 Review of Symptoms Form Recognized organ systems are: Review of Symptoms form Using a Template in the ROS form: How to dictate a positive finding and a negative finding in a template: Changing a finding to positive: Changing a finding to negative Add a positive or negative finding Creating an Alias ROS Aliases Past Medical History Social History Tobacco History Alcohol History Living situation Family History Allergies Medication History Vitals Physical Exam Exam templates Diagnosis Assessment Plan... 33

4 Prescribe... 34

5 NoteSwift for Amazing Charts 4 Introduction First Things First 1. Do you have Dragon Medical Practice Edition Installed? 2. Do you have Amazing Charts installed? 3. Do you have NoteSwift installed? If you can answer yes to all three, then proceed to training! If you need to install any of the programs listed above, do so before proceeding. Assumptions: This document assumes that you are comfortable using speech recognition and that you are able to work with your EHR capably with or without speech recognition. This document will not teach you how to use speech recognition, or how to use your EHR. If you are not comfortable with either, seek training before using NoteSwift.

6 About This Document: Typographic Weirdness and Helpful Icons There are certain typographic conventions in this document which, once you learn them will help with you discern what is typed, clicked, or said in each example and exercise. NoteSwift commands, words you say to NoteSwift when you want something to happen, are in bold and initial capitals such as History of Present Illness. Where you need to pause your voice for a moment in between commands, we put a comma in the instruction. For example, EXAM, Neuro, numbness on the right foot. You would pause briefly where the commas appear. If the NoteSwift form has a Next button, it allows more than one listed item (such as in the Allergies, Medications, Tobacco sections of Amazing Charts). Say Next, to add each item into your form. When done say Done or press the Next hotkey to enter all information into the form. The Good Doctor icon. Whenever you see this icon, it means we have some important and helpful information for you from the Good Doctor himself, Dr. Chris Russell, Founder and CEO of NoteSwift. These tips and tricks will help you learn best practices when working with NoteSwift and your EHR. Here is your first tip from the Good Doctor! Often, it can be quickest to use the hotkey assigned to the Next button to get through the forms and templates. The Next hotkey can be assigned through the NoteSwift Options menu, or through the Powermic options found in DMPE. You can also assign a Next or Done hotkey on your computer s numeric keypad.

7 NoteSwift for Amazing Charts 6 NoteSwift Forms NoteSwift forms allow you to dictate free text narrative, or, dictate structured data where NoteSwift does the searching for you from a defined list. In this document we go through each NoteSwift form and show you how to create the patient note quickly and easily whether you need free text or structured data. NoteSwift Forms are: Chief Complaint History of Present Illness Review of Systems Past Medical History Social History Family History Allergies Current Medications Vitals Physical Exam Assessment Plan

8 Chief Complaint Form Have DMPE, Amazing Charts, and NoteSwift open. Call up the Chief Complaint form. Chief Complaint The NoteSwift Chief Complaint form appears. Dictate the patients complaint. For example: Low Back Pain The words low back pain will appear in the Chief Complaint form. If there was existing highlighted text already in the form, any new dictation will replace it. Use your hotkey to click the Done button or, say: Done

9 NoteSwift for Amazing Charts 8 History of Present Illness Form Call up the History of Present Illness form. HPI The History of Present Illness form appears. Dictate the patients history. For example: The patient presents to the office with a back ache lasting for 24 hours. It is worse if he sits for a long time. He has pain radiating down the right foot. He has taken over the counter medication with no relief. The words you dictated will appear in the HPI form. If there was existing highlighted text already in the form, any new dictation will replace it. Use your hotkey to click the Done button or, say: Done

10 Other Commands Available in the HPI Form: Append moves the cursor to the end of existing text and adds additional dictation to the end of previous dictated notes. Recover brings back the text from your prior HPI dictation. This is useful if the text was lost. Say Append if you wish to add text to the end of existing text. Say Recover, if you wish to recover text from a previous dictation.

11 NoteSwift for Amazing Charts 10 Review of Symptoms Form The ROS form allows the provider to quickly modify an existing ROS from a prior visit or from a template. NoteSwift is good at recognizing varying terms for ROS text, but it expects a certain format. Organize the ROS by organ system. The name of the organ system is followed by a colon, and then the positives and negatives are placed after the colon. Generally templates are used to document negatives, but they can be used for positives as well. Recognized organ systems are: General HEENT Neck Chest Cardiovascular Abdomen Neuro Musculoskeletal GU Psych Endocrine

12 Review of Symptoms form Call up the Review of Symptoms form. ROS The NoteSwift ROS form appears. Dictate the review of symptoms. Remember to pause where you see the commas. For example: General, No fever or weight loss. Chest, No dyspnea or cough. Cardiovascular, No chest pain or palpitations. The first word you dictate, such as General, will appear in the Finding field. No fever or weight loss will appear in the Details section. After you click Next, you will see the review of each symptom appear in the preview window. When you are finished dictating all symptoms, click Done and the text will appear in the Amazing Charts ROS field.

13 NoteSwift for Amazing Charts 12 Using a Template in the ROS form: If you would like to use a pre existing template in the ROS form, call up your ROS templates. ROS Template The Amazing Charts window opens showing ROS templates available (your window may look different depending upon whether or not you have preexisting templates.) In the image above, we have an existing template for a patient with a sore throat. Say Sore Throat The name of the template appears. Click Done. The text of the sore throat template appears in the ROS form in the Amazing Charts Window.

14 If you have templates you use regularly, you can assign a name that is easily spoken to call up your templates. NoteSwift allows you to create an Alias for each Template. In the image on the previous page there is a template called denver m (10-12 mean) which includes this text in the template: Developmental: pulls to a stand, cruises, walking, voluntary release of objects, helps with dressing, affective sharing, uses parent as secure base, separation distress, one step command (with gesture) You can change the name of the template to something easier to say. For example, well baby. This is done in the Amazing Charts software in the Add/ Edit Template section. See Amazing Charts help for more information.

15 NoteSwift for Amazing Charts 14 Once you have a template with an easy to say name like Well Baby, you can call up the ROS Templates form ROS Template The templates appear. Click Alias. In the spoken form type or speak the name of the template you wish to say. In this example, well baby.

16 In the EHR Term field type in the same thing, well baby. Click Done and you will now have a Template called well baby that you can call up anytime.

17 NoteSwift for Amazing Charts 16 How to dictate a positive finding and a negative finding in a template: To dictate a positive finding in a Template, call up the NoteSwift form where you used your template, and dictate the organ system associated with the finding, then dictate the finding. For example: ROS Chest, Positive Chest Pain, No Palpitations. Changing a finding to positive: The NoteSwift ROS form can quickly modify existing findings or add new findings. Using the example from the previous page, let s say you want to document the patient has chest pain in the Review of Symptoms form. Say ROS to open the form. Cardiovascular, Chest Pain, On Exertion Click the Next button on your PowerMic II The Cardiovascular text will change to: Cardiovascular: POSITIVE CHEST PAIN (ON EXERTION). No palpitations. The Good Doctor Says: The ROS form by default starts with the cursor in the Finding box and set to Positive. Speak the name of the finding when the cursor is in the Finding box. NoteSwift highlights that term and jumps to the Details box. You can then optionally dictate some narrative text about that finding. Press the Next button and the ROS is changed. When finished, click Done.

18 Changing a finding to negative Let s say that you see a patient in a follow up. He had chest pain on his previous visit but it has now resolved. Here is the ROS text: Cardiovascular: POSITIVE CHEST PAIN (ON EXERTION). No palpitations. To change the chest pain entry to negative, bring up the ROS form. ROS, Negative, Cardiovascular, Chest Pain, Next, Done. The CHEST PAIN entry will change to negative. When the NoteSwift ROS form has been set to negative it will remain so until explicitly changed.

19 NoteSwift for Amazing Charts 18 Add a positive or negative finding There are three ways to add a finding. The preferred way is through the use of a term that has a built in system associated with it. For instance, NoteSwift knows that the term numbness belongs in the Neuro organ system. The Good Doctor Says: You can add other terms to your user profile. Your added terms must use the organ system name that NoteSwift expects. The organ system names are taken from the E/M coding guidelines. Here are the organ systems again for your convenience: General HEENT Neck Chest Cardiovascular Abdomen Neuro Musculoskeletal GU Psych Endocrine

20 Creating an Alias If you would like to change the term s organ system, create an Alias for your desired term. To add a term that has an alias, just say the name of the term, pause your voice and then optionally speak any text you want to associate with that term. The system name will appear in the Aliases box. Press the Next button and the item is entered into the Preview. For instance: Numbness Occasionally In The Right Hand. Press the Next hotkey and the following is added: Neuro: Numbness (OCCASIONALLY IN THE RIGHT HAND). If there is other text already in the Neuro section, the term is added appropriately. To set findings to negative, say Negative. The Good Doctor says: You can dictate ROS terms (detailed in the next section) without aliases. Speak the name of an organ system, pause, and then speak the finding, NoteSwift will place the finding under the spoken organ system when Next is pressed. If a term is spoken that does not have an alias, and no organ system is provided, NoteSwift will place the term in the General section. When you are done dictating ROS findings, say Done or press the Done button to enter the Preview text into Amazing Charts, or simply call up the next NoteSwift form into which you want to dictate.

21 NoteSwift for Amazing Charts 20 ROS Aliases ROS Aliases are created and changed in the ROS Alias form. To assign a finding to an organ system, put the finding in the Phrase box and the organ system name in the System box. When done, press OK. Whenever you dictate the item in the ROS box, it will be placed in the organ system designated.

22 Past Medical History The Past Medical History form is a free text form. Dictate your text and press the Next hotkey to enter it into Amazing Charts. The Dragon commands New Line and New Paragraph are often helpful in this form.

23 NoteSwift for Amazing Charts 22 Social History To enter an item into the Social History form, speak the item you want to dictate, pause, and then optionally speak the description related to that item For example, to note that the patient works in a warehouse, say, Employment, Warehouse Work. Press the Next hotkey. The text appears in the Preview. Once done your dictation Click or Say Done and the text appears in the Social History Form of Amazing Charts.

24 Tobacco History In the tobacco Section of the Social History form, Amazing Charts has provided several options to choose. Dictate a matching option to have that text appear in the tobacco form. For example, say one of the following: Current Every Day Smoker Current Some Day Smoker Smoker Current Status Unknown Unknown If Ever Smoked Former Smoker Never Smoker NoteSwift will guide the provider through documentation of the smoking history. If a patient is a smoker, say Current Smoker Then, press the Next hotkey. The item field will then ask for the Packs/Day. Dictate the number of packs/day. Two Press the Next hotkey and the item field will ask for the Years Smoked. Dictate the answer in the Note field. 20 You can document the other options above in a similar manner. To enter the Preview into Amazing Charts, say Done The Good Doctor Says: Don t smoke as it is bad for your health!

25 NoteSwift for Amazing Charts 24 Alcohol History To document alcohol use in the Social History Form say Alcohol The word alcohol will appear in the item field. Pause your voice and dictate the patients alcohol use. For example: 2 Glasses of Wine Per Evening Click next if you wish to add anything else to the social history, or click Done to insert the text into the Amazing Charts window. Living situation The patient s living Situation is easily dictated also in the Social History Form by saying: Living Situation The words will appear in the item field. Pause your voice and dictate the patients situation. For example: Lives Alone Click next if you wish to add anything else to the social history, or click Done to insert the text into the Amazing Charts window.

26 Family History The Family History form is a free text form. Dictate your text and press the Next hotkey to enter it into Amazing Charts. The Dragon commands New Line and New Paragraph are often helpful in this form.

27 NoteSwift for Amazing Charts 26 Allergies If the patient has no Allergies, say None and press the Next hotkey. To document an allergy, speak the name of the allergen into the Allergen box. NoteSwift will search for the allergen in Amazing Charts and the cursor will jump to the Reaction box. If you dictated one of the Common Allergens listed in Amazing Charts (in the Add Common Allergy Section in the image below), NoteSwift will not search but will instead check the item when you press the Next Hotkey. After the Allergen is dictated, NoteSwift will jump to the reaction box. You can optionally dictate the reaction that the patient experienced. Press the Next hotkey to enter the allergen into Amazing Charts. The Good Doctor Says: If the Amazing Charts search lists more than one result, NoteSwift will use the first item listed. If you want to use a different item, single click on the item you want in Amazing Charts before pressing the Next hotkey.

28 Medication History Call up the Medications History Form in NoteSwift. If the Current Medications form Window does not appear make sure that the Amazing Charts window has the focus on it. If the focus is not on Amazing Charts the Meds window will not appear. If Amazing Charts has the focus the NoteSwift Meds form will appear. Current Medications Dictate the medications your patient is taking. Try these examples to see how to dictate medications in this form. (*Say mg as milligrams.) Lisinopril 20 mg daily Aspirin 300 mg daily Norvasc 5 mg daily NoteSwift does the lookup for you and puts the dose and count in the right places. This can be very helpful if a patient takes several medications.

29 NoteSwift for Amazing Charts 28 Vitals NoteSwift speeds entry of vital signs. NoteSwift will ask for the vital signs in order, beginning with Weight. To enter the weight, just say the patient weight (without units) and press the Next hotkey. After the Next key is pressed, NoteSwift will ask for the Height. You can cycle through all six vitals in order by pressing the Next hotkey to advance. If you want to go directly to a particular vital sign, just say its name. For example, to go directly to the blood pressure field, say: Blood Pressure Then the dictate the numbers. For example, 180 over 60. Press the Next hotkey to enter it.

30 Physical Exam The Physical Exam form is a free text form and also allows for the use of templates. You can use existing Amazing Charts templates or any that you have created on your own. Call up the Physical Exam form: Exam Dictate whatever you wish into the form. Remembering to pause your voice at each comma you see in the example below: Orientation, oriented to person place and time. Memory, recall 3/3 objects at 5 minutes. Language, follows 3 step commands. Mood, mood is normal.

31 NoteSwift for Amazing Charts 30 Exam templates If you would like to call up an exam template rather than use free text dictation, call up the exam templates form. Exam Template In the image below you see the list of existing templates in Amazing Charts. Your list will look different from this image. If you would like to be able to call up an oft used exam template by name, create an Alias for it. Click on the Alias button in the NoteSwift form.

32 In the Alias form, write in what you would like to say to call up the template each time, in the Spoken Alias field. In the example below, we would like to use the asthmatic bronchitis template so asthmatic bronchitis appears in the spoken alias field. In the EHR Term field type or speak in the name of the template as it appears in the amazing charts physical exam templates window. In this example the template is called dx: Asthmatic Bronchitis. Click Done. The next time you wish to use the template, call up the Exam Templates form, then, say your template name. Exam Template Asthmatic bronchitis Done

33 NoteSwift for Amazing Charts 32 Diagnosis To add a diagnosis to the patient s chart, say the diagnosis you want in the item box. When you pause, NoteSwift will search for the diagnosis and jump to the Note field. You can then dictate an assessment narrative associated with that diagnosis. Press the Next hotkey to enter the diagnosis into the chart. If the Diagnosis search returns more than one item, NoteSwift will use the first item on the list unless you click on another item on the list, in which case it will use that item.

34 Assessment The NoteSwift Assessment Form is a free text form. Dictate your assessment as you wish. Click Done when finished. Plan The NoteSwift Plan Form is a free text form. Dictate your plan as you wish. Click Done when finished.

35 NoteSwift for Amazing Charts 34 Prescribe To prescribe a medication in a patient note, call up the Prescribe form and dictate the desired prescription. For Example: Prescribe, Oxybutynin 5 mg Daily NoteSwift enters the medication and correct dosage. Once all data is included, you can click on the View Draft button in the Amazing Charts window to see what your complete patient note will look like.